Routine inspection·January 26, 2024

Licensing Program Analyst (LPA) Mita Partoza conducted an unannounced required annual inspection to the facility. The inspection was originally started on 1/24/2024 and this report is a continuation of the unannounced required annual visit. LPA met with administrator (ADM) Marie Jan Foronda-Cayabyab and amended the record that was erroneously recorded at a different facility on 1/24/2024. During today's visit 1/26/2024. LPA met with ADM and 5 staff. Currently the facility has 15 residents and 15 Out of 15 are ambulatory. During visit, LPA toured the facility to include the living room, dining room, kitchen, bedrooms, bathroom, storage area, and backyard. Staff room was inspected, 2.5 bathroom were inspected. The room temperature measured at 68-75F and the hot water temperature measured from 114.6F to 117.7F LPA with ADM tested the fire alarm and carbon monoxide system and found to be in good working condition. Night lights are also observed and are in good working condition. All designated emergency exits and passage ways are clear from obstructions. LPA observed the fire extinguisher in the kitchen is missing inspection tag that needs to conform with the regulations adopted by the State Marshall. page 1 of 2 continued on page 2 (LIC 809C). continued from page 1 (LIC 809) Toiletries such toilet paper, paper towels, toothpaste are inspected and found to be in ample supply. Toxic materials such as laundry detergent, disinfectant are inaccessible to residents and stored in a locked cabinet. LPA observed there is ample amount of perishable food for 2 days and 7 days non-perishable food supply for residents and staff as required by regulation. LPA and ADM reviewed 7 resident record, the resident's centrally stored medication and destruction record (CSMDR) and their P&I (cash resource) and found that all records are updated per regulations with no discrepancy. All designated emergency exits and passage ways are clear from obstructions. Staff and Administrator were reminded about infection control plan. A deficiencies was cited per California Code of Regulations, Title 22 during today's visit. This report was reviewed with administrator Marie Jan Foronda-Cayabyab. end of report page 2 of 2